History

Systems Review

Tests and measures

History subheadings

Demographic information:

Patients Name

address

admission date

date of birth

sex

dominant hand

race

ethnicity

language

Education level

advanced directive preferences

Referral source

reasons for referral to therapy

History subheadings;

Current conditions/chief complaints:

onset date of problem

any incident that caused or contributed to the problem

prior history of similar problems

how the patient is caring for the problem

what makes the problem better or worse

other practitioners the patient has seen for the problem

History subheadings

Patient goals:

History subheadings

Prior level of function:

level of function prior to the most recent onset of current complaint

if a chronic condition the function prior to the most recent onset of symptoms

History subheadings

social history

cultural and religious beliefs that might effect care

who does the person live with prior to admission

who will the person live with after discharge

available social and physical supports now and after discharge

availability of a caregiver

History subheadings

employment status:

does the patient work

full time

part time

Student

work at home/office

retired

History subheadings:

Living environment:

assistive devices and equipment the patient uses

type of residence

info about the residence

     Steps-stairs-ramps-etc

use of community services such as:  home health services, meals on wheels, hospice, homemaking services, other programs

History subheadings:

General health status:

Patients self rating of general health

any major life changes during preceding year

History subheadings:

social/health habits:

smoke

drink

exercise habits

physical activities ie hangliding, base jumping, dancing, etc.

History subheadings:

Family health history:

general screening for a family history of

heart diseae,

hypertension,

stroke,

diabetes,

cancer,

psychological conditions,

arthritis,

osteoporosis and

other conditions.

History subheadings:

patient medical/surgical history:

History subheadings:

Functional status/activity level

mobility

transfers

gait

selfcare

home management

community, school and work activities

that apply to current condition

History subheadings:

Medications:

History subheadings:

growth and development:

most applicable to pediatrics

include developmental history

History subheadings:

Other clinical testsL

contradicts information given by another source

or

it is the patients belief and not factual or documented medically